2004, 05-27 Notice of Hazardous ConditionsAN_
1ST*
Utilities
NOTICE�'OF HAZARDOUS CONDITIONS
Customer Name
Address
TYPE OF
NOTIFICATION:
S-0308 (08-01)
Phone Number
City
IJ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of life. The equipment has been disconnected or left inoperable, and shall not be turned back on until such repairs have been completed
by a qualified HVAC dealer, contractor, or service agency, and the equipment has been brought up to current safety standards. Do not
attempt to use this equipment until it has been repaired.
Equipment Type:
CONDITIONS
FOUND:
Location.
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
CFH
A 1A- t2
Meter Left ❑ Off Et On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ Owner Tenant
Customer Signature
Service Representative Date
❑ Agent
❑ Refused to Sign
Time
White Copy - Customer Yellow Copy - Attach to Service Order
Pink Copy - Authority Having Jurisdiction Hard Copy- Appliance
am/pm